Neurological Emergencies PDF

Neurological Emergencies PCP  Objectives Discuss/Understand common terms Understand/Differentiate between A/Ox4 and AVPU Familiarize with AEIOU-TIPS and relation to Neurological Emergencies Discuss/Understand different types and severities of common chronic a...

Neurological Emergencies PCP  Objectives Discuss/Understand common terms Understand/Differentiate between A/Ox4 and AVPU Familiarize with AEIOU-TIPS and relation to Neurological Emergencies Discuss/Understand different types and severities of common chronic and acute Neurological emergencies and pathologies Discuss common medications used to treat Neurological emergencies  Neurological Emergencies Different types How they present What to do about them  Definition Serious neurological problems involve the CNS and affect the main CNS functions: 1. Cognitive 2. Cerebral homeostasis 3. Motor control 4. Sensation 5. All of the Above  AVPU AVPU Alert Verbal Painful Unresponsive If a patient is Alert, use A/Ox4 with GCS Generally only used when patient has decreased GCS/LOC, or patient is incapable of verbal communication (PEDS)  A/Ox4 A/Ox4 1. Person 2. Place 3. Time 4. Event Generally used with verbal adults Consider why pt doesn’t know one of the four  AEIOU-TIPS AEIOU TIPS Alcohol, apnea, anaphylaxis Epilepsy, environmental (heat / cold) Insulin (diabetes) Overdose Uremia Trauma Infection Psychiatric, poisoning Stroke, shock All of these can cause changes in LOC  Headaches The brain itself has no pain receptors, so headache pain is the result of stimulation of the surrounding tissues and structures May be caused by CO, cyanide, solvents, medications (nitrates, contraceptives), depression, stress, cold environment, HTN, trauma, tumor, etc.  Headaches Tension A generalized headache caused by contraction of the muscles of the scalp and neck Pain generally comes from neck and up along back of head or through temples Most of you probably have one from class  Headaches Vascular (Migraine) Caused by dilation of cerebral blood vessels More blood = more pressure Usually results from hypertension, commonly with a diastolic pressure of 120mmHg May have an aura May be generalized/localized Typically recurrent  Headaches Cluster Originate in the hypothalamus Are a result of abnormal serotonin levels May last up to 2 hours and occur 2 or 3 times per night, waking the patient up Generally more intense at night Follow biological rhythm not only at nights, but seasonally/annually  Headaches Infection Can be mere nuisance to life threatening Viral infections can either directly or indirectly cause headache May produce intense congestion in the nasal passages, which at times causes a blockage of the sinus drainage passages Severe headache may also result from viral infections that specifically attack the brain and its coverings, such as encephalitis and meningitis  Cerebrovascular Accidents (CVA) Are caused by a disruption of blood flow to any part of the brain Lack of oxygen leads to infarction and eventual necrosis Present with contralateral symptoms that vary in severity Different locations in the brain create different S/S Ischemic, and hemorrhagic, Transient Ischemic Attack  Cerebrovascular Accidents (CVA) Ischemic-90% of all strokes Hemorrhagic-10% of all strokes  Occlusive Stroke Thrombotic Caused by a clot occurring at the site of atherosclerosis or other damage TIA’s are warning signs like Angina is for the heart Onset may be slow or preceeded by ++ TIAs as clot forms and breaks off  Occlusive Stroke Risk Fx Smokers Sedentary lifestyle Obese Diabetics HTN What do these all have in common?  Occlusive Stroke Embolus Clot formation occurs at a remote site, breaks free and travels to the brain Rapid onset  Occlusive Stroke Embolus Smokers Sedentary lifestyle Obese, diabetics A-Fib HTN  Hemorrhagic Stroke A rupture of a cerebral artery causes bleeding into brain tissue Two problems: Ischemia Intracranial pressure Primarily caused by hypertension BP 220>/110> indicator for hemorrhagic Usually a rapid onset from headache to coma  Transient Ischemic Attack (TIA) Is a temporary occlusion of a cerebral artery that resolves itself within 24 hours Is a grave predictor of future stroke, with 30% chance of CVA occurring soon after  Signs and Symptoms Any sudden onset neuro symptoms: Headache Dizziness Photophobia Numbness Altered LOC or Coma Altered pupillary reflexes Altered CN assessment Other symptoms may include: Unexplained HTN AV Blocks Positive Babinski  Signs and Symptoms And of course, unilateral weakness S/S are dependant on the extent of ischemia and location in the brain. Your job is not to rule out CVA,it’s to rule in anything that COULD be a CVA.  Signs and Symptoms Cranial nerves are ipsilateral peripheral nerves, while motor tracts from the brain cross over (decussate) at the medulla. Therefor, an occlusive stroke on the left side of the brain would cause ipsilateral CN involvement (such as pupillary effects) and contralateral muscular paralysis.  Assessment-FAST+ Facial droop Clench jaw (CN VII) Numbness/Tingling? Puff out cheeks? Smile? Arm drift & Leg strength Grip strength Arm drift? Pronator drift? Numbness/tingling? Speech Ask patient or family The sky is blue in cincinnati Move tongue left and right (CN XII) Time < 6hrs (increased from 4.5) + Any sudden onset neurodeficit listed on the previous page with no other reasonable cause  LAMS (Los Angeles Motor Scale) Is not a Dx method for CVA Is an evidence based method to evaluate SEVERITY of stroke once you have suspected one from a complete neuro assessment. Face Facial droop +1 Arms Slow drift/pronator +1 drift Rapid drop +2 Hands Unilateral weakness +1 Unilateral paralysis +2  Treatment of Stroke Airway management O2 therapy IV therapy (18g R AC preferred site) Rapid transport to appropriate facility (call ahead for stroke team) Positioning Upper body at slight elevation, to aid in reducing ICP Be cautious as positioning can cause the patient to lose their airway D50W 12.5g q10m MAX 25g to BGL 3.0  Seizures Two Main Types GENERALIZED involving both hemispheres of the brain PARTIAL involving only one hemisphere/portion of the brain  What is a Seizure? A typical brain has about 10 billion cells called “neurons.” These neurons are all bunched up side-by-side, and communicate with each other with electrical charges. Certain chemicals in your brain help put brakes on all of this electrical activity.  What is a Seizure? “Short circuit” occurs Neurons keep firing Whatever those neurons control keep firing E.g. Muscles Same kind of short circuit can cause total limpness as well Seizures can use +200 times O2 and glucose in the brain  Generalized Seizures Absence Formerly called petit-mal or behavioural, they are brief periods of abnormal, purposeless behaviour ‘Spaced out’ appearance Last only a few seconds No general postictal state Patient will have no memory of event Children may grow out of them, or they may develop tonic-clonic seizures  Generalized Seizures Tonic-Clonic (Grand Mal) Characterized by a sudden onset of loss of coordination and consciousness Violent jerking of body, contraction and relaxation of opposing muscle groups Lasts 3-5 minutes normally, but can last 30 minutes Longer the seizure, longer/deeper the postictal state May present with incontinence  Generalized Seizures Postictal Phase Period where consciousness is progressively regained Varies greatly in length between patients Patient will be tired due to energy expenditure Possible hypoglycemia from event Patient usually has retrograde amnesia Patient may not be able to protect airway Recovery position, watch for vomit Generalized Seizures  Generalized Seizures https://player.vimeo.com/video/102846137  Status Epilepticus Describes any period of seizure activity lasting 30 minutes or more Recurring seizures without full consciousness regained Remain in partial postictal when new seizure starts Can be drug, trauma, congenitally induced  Partial Seizures Focal (Previously “Simple” Partial) Present in a single muscle group Can also have sensory symptoms such as vertigo, hallucinations, auditory or visual disturbances No decrease in LOC No postictal phase Can develop into deeper/more severe seizures  Jacksonian Seizure A form of epilepsy involving brief alteration in movement, sensation or nerve function caused by abnormal electrical activity in a localized area of the brain Generally repetitive Smacking lips, twitch of hand, etc Seizures of this type typically cause no change in awareness or alertness.  Jacksonian Seizure Jacksonian seizures are extremely varied involving purposeless movements Turning the head, Eye movements, Smacking the lips, Mouth movements, Drooling, Rhythmic muscle contractions in a part of the body, Abnormal numbness, Tingling, Crawling sensation over the skin.  Partial Seizure Complex Partial Consists of behavioural changes and an altered LOC Usually have an aura Can still perform complex tasks such as walking or driving Generally quite short in duration No memory of event  Treatment Protect the patient from hurting themselves Manage the airway, give high-flow oxygen IV Therapy Call for ALS (medications) Transport rapidly Prepare for a possible re-occurrence  Treatment With the exception of a Dx of Epilepsy, seizures are a symptom of an underlying pathology and require a CT In the presence of a Dx of epilepsy, it is important to ask about any changes in quality or quantity of seizures. Changes from normal may warrant a CT or medication adjustment.  Todd’s Paralysis Condition after a seizure Pt’s postictal state resembles that of a stroke pt Hemiparalyis, CSS deficits, slurred speech Corrects itself as postictal state lessens  Seizure Medications Dilantin (phenytoin) Suppresses seizure activity without depressing the CNS, by blocking sodium channels Tegretol (carbamazepine) Same as Dilantin Phenobarbital (many names) The most common med, is a barbiturate but a weak CNS depressant Depakene (valproic acid) The only treatment for absence seizures  Pre-Hospital Seizure Medications Valium (diazepam) ALS Versed (midazolam) ALS Both are benzodiazepines that potentiate GABA, an inhibitory neurotransmitter Requires greater stimulation to cause a seizure  Chronic Disorders Amyotrophic Lateral Sclerosis Also called Lou Gehrig’s or ALS Is a muscular dystrophy caused by degeneration of motor neurons of the spinal cord Presents as a progressive wasting of muscles with no effect on mental status  Chronic Disorders Cerebral Palsy Is caused by a congenital defect or lesion May result in a variety of signs and symptoms  Chronic Disorders Multiple Sclerosis A disease resulting in spotty destruction of myelin Starts in the teen years and has a highly variable course  Chronic Disorders Parkinson’s A progressive, degenerative condition of the brain tissue, resulting in tremors, loss of motor control, and speech difficulties  Chronic Disorders Poliomyelitis Highly contagious infectious disease Most recognized for its destruction to the nervous system causing paralysis. The majority of infected individuals have no symptoms and few have mild symptoms. Of those persons that do acquire the infection, 2 percent or fewer may develop paralytic disease.  Infectious Disorders Encephalitis Infection of the brain tissue by a bacteria or virus, which usually occurs first in another area of the body and migrates to the brain Inflammation and necrosis can lead to altered cerebral function Can present with all of the neurological S/S  Infectious Disorders Guillian Barre Syndrome Typically preceded by a viral infection, it has unknown etiology and presents as progressive weakness distally moving inwards to the trunk  Infectious Disorders Meningitis Infection and inflammation of the meningeal membranes, caused by a virus, bacteria, or fungus Presents with a wide array of mental and behavioural changes Increased ICP, fever, N/V, headache, nuccal rigidity, intolerance to light / sound, rash  Tumors S/S depend on the size, location, and rate of growth (structural vs vascular) Benign Has no signs of cancer. The growth of the cells in the tumor, cyst, lump, tissue, or cells is under control. There is no spread to nearby tissue or to other parts of the body Malignant Cancerous A growth that tends to spread into nearby normal tissue and travel to other parts of the body  Meds & Hx Discussion: – Pertinent history questions – Commonly prescribed medications  AHS Protocols Review all pertinent protocols Questions?